NCLEX Challenge Questions

B

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? a) Administer epinephrine. b) Maintain a patent airway. c) Administer a bolus of normal saline solution. d) Monitor vital signs.

C (possible placenta previa or abruptio)

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? a) Place an indwelling catheter. b) Perform a cervical examination. c) Monitor fetal heart tones. d) Prepare the client for cesarean birth.

D (assessing airway - think ABCs)

A client is brought to the emergency department after a house fire. What is the priority assessment by the nurse? a) Assess the level of pain and medication allergies. b) Assess the depth and total surface area of burns. c) Collect a full set of vital signs and spheres of orientation. d) Assess oxygen saturation and the client's ability to speak.

A

A client with pneumonia has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobe. Which action should the nurse take first? a) Apply oxygen b) Administer antibiotics c) Assess nutritional intake d) Encourage bed rest

D

A health care provider has placed a stat order for a urine specimen for culture and sensitivity. What is the best way for the nurse to delegate this task to an unlicensed assistive personnel? a) We need a stat urine culture on the client in room 101. b) Please get the urine for culture for the client in room 101. c) A stat urine has been ordered for the client in room 101. Would you get it? d) We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab.

D

A nurse caring for an infant with neonatal bronchopulmonary dysplasia (chronic lung disease) administers furosemide. What is the priority intervention following the administration of this medication? a) Obtain daily weights. b) Obtain vital signs every 2 hours. c) Obtain a vision screen. d) Monitor electrolyte status.

B (suggests tension pneumo. C is not an emergency)

A nurse has received a change-of-shift report on four clients. Which client should the nurse assess first? a) client with a recent lung transplant scheduled to begin pulmonary rehabilitation b) client experiencing tracheal deviation following a subclavian catheter insertion c) client with a pleural effusion who reports severe stabbing chest pain d) client with right-sided heart failure who has 4+ bilateral edema in the legs and feet

D (think of primary prevention) (this answer is more correct than RF because some RF are nonmodifiable, like female gender, so parents won't be able to do anything about this)

A nurse is teaching a group of parents about urinary tract infections (UTIs) in children. What is the priority educational topic for this group of parents? a) risk factors for UTIs in children b) how to collect a midstream urine sample c) how to identify symptoms of UTI d) interventions to prevent UTIs

A (b/c will take less time than B)

A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes priority? a) a child who develops a fever during a blood transfusion b) a child admitted from the postanesthesia care unit who has a blood-saturated surgical dressing c) a physician waiting on the telephone to give the nurse a verbal order d) a child with asthma who is wheezing with an oxygen saturation level of 96%

A

On the fourth day after surgery, a client's incision is red and inflamed. There is moderate drainage from the incision. The client has a temperature of 102°F (38.9°C). The total white blood cell (WBC) count is 10,000/mm3 (10 × 109/L). What should the nurse do first? a) Notify the health care provider (HCP). b) Cleanse the incision site with soap and water. c) Encourage the client to increase the fluid intake. d) Place an absorbent dressing over the incision.

D (most likely to be unstable, not worried about unstable BP in B b.c on hospice)

The nurse is assigned to care for four clients. Which client should the nurse assess first? a) A client admitted two days ago with heart failure, blood pressure of 126/76 mmHg, and a respiratory rate of 22 breaths/min b) A client with end-stage, right-sided heart failure, with blood pressure of 78/50 mmHg, who is on hospice care c) A client admitted one day ago with thrombophlebitis who is receiving IV heparin d) A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem

B

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? a) debriding and grafting the burns b) diluting the chemicals c) applying topical antibiotics d) applying sterile dressings

D

The parent of a 2-year-old with epiglottitis states a need to pick up the older child from school. The 2-year-old child begins to cry and appears more stridorous. What is the nurse's priority action? a) Ask how long the parent will be gone. b) Tell the 2-year-old child everything will be all right. c) Tell the 2-year-old child the nurse will stay. d) Ask the parent if there's anyone else who can meet the older child.

C

What action should the nurse take first when a client is coughing up pink, frothy sputum? a) Apply supplemental oxygen b) Plan to administer a diuretic c) Place the client in high-Fowlers position d) Start an IV line

A (pv infection and rupture) (keep moist until can be surgically repaired! Do not palpate!)

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele? a) Carefully position and handle the omphalocele. b) Keep the omphalocele dry. c) Cover the omphalocele when parents visit. d) Gently palpate the omphalocele to assess for changes.

B (A may have happened before they were with current foster parents)

Which family should the nurse determine as most in need of follow-up? a) a two-parent family with a foster child who has a history of caustic liquid ingestion b) a single parent with a toddler who has third-degree burns over 20% of the body c) a two-parent family whose 3-year-old has a fractured leg from an automobile accident d) a single mother with a 7-month-old child whose immunizations are delayed

A (B is incorrect b/c doesn't address pt's potential of self-harm)

The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include? a) Use a caring approach to maintain close observation of the client b) Develop a strong and healthy relationship with the client c) Obtain an order for an antianxiety medication to keep the client calm d) Encourage the client to avoid over-stimulating group activities

A (keeps airways moist and liquefies secretions)

The nurse is planning care for a child admitted to the pediatric unit with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first? a) provide humidified oxygen b) keep ambient air temperature cooler than normal c) give palivizumab vaccine d) keep fluids at a minimum

C (A is wrong because would reduce ICP, not intraocular pressure)

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. What is the most important action by the nurse? a) Elevate the head of the bed to reduce intraocular pressure b) Preventing secondary acute tubular necrosis c) Preparing to administer hypertonic saline or mannitol per provider order d) Lower the head of the bed to improve cerebral perfusion